National Council of Certified Dementia Practitioners



|"As the number of confirmed cases of the Novel Coronavirus (COVID-19) increases across the United States, the NCCDP finds it |

|necessary to offer all NCCDP seminars through December 2020. |

| |

|The following seminars will still take place on the day and time as scheduled; however, registered participants will receive |

|detailed login instructions (which include needing a laptop/desktop and headset) to participate live/online." |

| |

|Anyone wishing to attend the ADDC online seminars, due to the National crisis, there are no distance restrictions. Contact the |

|listed online trainers who have seminars posted and register directly with the approved online trainer.  |

NCCDP National Council of Certified Dementia Practitioners

55 Main Street, Suite 102

Sparta, NJ 07871-1909 USA

Within USA Toll Free 1- 877-729-5191

International Calls 1 973.729.5191

 

NCCDPCORPORATE@

Alzheimer’s Disease and Dementia Care Seminar Registration Form

Thank you for being the best part of the NCCDP

THIS FORM IS ONLY TO BE USED FOR SEMINARS PRESENTED BY The NCCDP CORPORATE STAFF. For all other seminars, please go to the calendar at calendarix. Register and submit payment directly with the trainer who is teaching the seminar for the date you have selected.

Please order online. However, if you wish to fax in the registration please fax to

973 860 2244. DO NOT EMAIL THE REGISTRATION FORM AS EMAILS ARE NOT SECURE! Use this form if you are paying by credit card and do not wish to use the NCCDP online shopping cart. You can also mail in the form.

If paying by check, please mail to NCCDP, 55 Main Street, Suite 102, Sparta NJ 07871-1909. Please feel free to use this form if mailing in a check. Make check payable to NCCDP.

SELECT THE SEMINAR AND DATE YOU WISH TO ATTEND:

|[ ] |December 9, 2020 - Grand Rapids, MI |

| |CLASS NOW HELD ONLINE VIA ZOOM |

|[ ] |December 11, 2020 - Sioux Falls, SD |

| |CLASS NOW HELD ONLINE VIA ZOOM |

|[ ] |December 14, 2020 - Baltimore, MD |

| |CLASS NOW HELD ONLINE VIA ZOOM |

|[ ] |JANUARY 8, 2021 - PHILADELPHIA, PA |

|[ ] |January 12, 2021 - Kansas City, Kansas |

|[ ] |January 14, 2021 - Atlantic City, New Jersey |

|[ ] |January 22, 2021 - Riverside, California |

|[ ] |January 26, 2021 - Tucson, AZ |

|[ ] |February 5, 2021 - Cleveland, OH |

|[ ] |February 14, 2021 - Portland, Oregon |

|[ ] |FEBRUARY 19, 2021 - ORLANDO, FL |

|[ ] |February 26, 2021 - Salt Lake City, UT |

|[ ] |March 5, 2021 - Las Vegas, NV |

|[ ] |March 9, 2021 - Tarrytown, New York |

|[ ] |March 12, 2021 - Omaha, Nebraska |

|[ ] |MARCH 26, 2021 - HARRISBURG, PA |

|[ ] |April 1, 2021 - Boston, MA |

|[ ] |April 16, 2021 - Denver, Colorado |

|[ ] |April 20, 2021 - Jacksonville, FL |

|[ ] |APRIL 23, 2021 - SAN DIEGO, CA |

|[ ] |May 4, 2021 - Santa Barbara, CA |

|[ ] |May 7, 2021 - Washington, DC |

|[ ] |May 11, 2021 - Chicago, Illinois |

|[ ] |MAY 14, 2021 - DES MOINES, IA |

|[ ] |May 25, 2021 - Tampa, FL |

|[ ] |June 8, 2021 - Colorado Springs, CO |

|[ ] |June 15, 2021 - Spokane, Washington |

|[ ] |JUNE 18, 2021 - PITTSBURGH, PA |

|[ ] |June 29, 2021 - Nashville, TN |

|[ ] |July 13, 2021 - Rockford, Illinois |

|[ ] |July 15, 2021 - Long Beach, California |

|[ ] |July 20, 2021 - Minneapolis, MN |

|[ ] |JULY 22, 2021 - KINGSPORT, TN |

|[ ] |July 30, 2021 - San Francisco, CA |

Seminar Registration Form

PAGE 2

Today's Date: _______________________________________________________

Your Name: _________________________________________________________

How Many in your party? _______________________________________________

Names of other participants: _____________________________________________

Your email address: ___________________________________________________

Company Name: _____________________________________________________

Your company address: _______________________________________________

Your cell number: ____________________________________________________

Your Work Number: __________________________________________________

Please charge my credit card in the amount of $195.00 per class per person for a total of $___________. I understand there is a $75.00 cancellation fee once the card is charged. If canceling 24 hours to the start of class or on the day of the class there is no refund. If canceling a class, you must send a certified letter / signed receipt.

Your signature: Please Sign: ________________________________________________

Today's date: ___________________________________________________________

Name on Card: ________________________________________________________

Name of Card: Please Check One: Visa __ Master Card __ AX__ Discover __

Number on card: ______________________________________________________

Expiration date: _______________________________________________________

Address where the credit card bill is mailed to:

____________________________________________________________________________

City: _______________________________ State: ___________________

Zip Code: _______________

EMAIL ADDRESS (required if paying by credit card): ________________________

We do not accept walk-ins. You can register any time for the class. But the latest you can register online is 48 hours prior to the start of the class. We pre ship notebooks to the venue and the only way we can insure we have enough notebooks is if we know in advance who is coming. If it is 24 hours prior to the start of the class please call 877 729 5191. You will receive an email confirmation prior to the start of the class.

There is a $19.00 returned check fee.

While certification promotes and maintains quality, it does not license, confer a right or privilege upon or otherwise define the qualifications of anyone in the healthcare field.

Please tell us how you heard about NCCDP : Please check all that apply.

θ Received a NCCDP  Fax about an upcoming seminar

θ Received a FAX OR BROCHURE from an approved NCCDP trainer about

an upcoming seminar 

θ Read about it in a newspaper, magazine, online social network or blog.

Please indicate the name: _____________________________________________

θ Heard about it in class or association. Which association? ____________________

θ Searched the Internet

θ Received NCCDP newsletter

θ NCCDP LinkedIn. If LinkedIn which group?

θ NCCDP Face Book

θ NCCDP Twitter

θ Friend / Co Worker

θ Board member: Which Association? ______________________________________

θ Association state, national conference or International Conference.  Which

Conference? _________________________________________

θ I heard about you because of NCCDP Alzheimer's disease and dementia Staff

Education Week press release.

θ Other? Please

explain:_______________________________________________________________________________________________________________________________________________________________________________________________________________

θ I don't remember

PLEASE RETURN ALL PAGES OF THE CDP APPLICATION.

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